How Covid-19 can transform health care
The pandemic disrupted life, livelihoods, education and health like little else in recent history. The world found innovations and adaptations to minimise some of the disruptions for some people, but not all. Health care disruptions, less amenable to home-based solutions, ranged across a very broad continuum — a shift in health-seeking behaviour, limitations in health infrastructure, difficulties in outreach to community members, lack of availability of human resources and interruptions in supply chains. Not all of these were limited to the context of the pandemic — some have pre-existed but got magnified in the context of the pandemic.
Covid-19 saw health care workers diverted to the much-needed task of preventing and dealing with infections, taking them away from their regular tasks, and thus, further reducing the availability of health care workers. Health care facilities were deployed for testing and treating patients, but this made them unavailable for regular services. Supply chains were disrupted due to lockdowns. When health facilities were functioning, citizens were either fearful or unable to travel to them or were unaware that facilities were functioning. All this led to significant disruption in the provision of essential health services such as routine immunisation, testing and treating tuberculosis (TB) patients, maternal and child health care and nutrition-related interventions.
But India is no stranger to innovation. A few months into the pandemic, there were a variety of interventions, which sought to address some of these barriers related to health human resources, demand for and access to services, and provision to the last mile. Innovations were found in at least four categories — leveraging technology, leveraging community platforms, strengthening frontline workers and augmenting supply chains.
Extensive interventions leveraged the digital platform such as remote counselling and consultation in several states; a child growth-monitoring app for remote monitoring of severely acute malnourished children in Rajasthan, Maharashtra and Madhya Pradesh; an Interactive Voice Response System-based solution in Uttar Pradesh for reminder calls to the community about immunisation sessions; digital surveillance applications for front-line workers for TB and Covid-vulnerability assessment in states such as Gujarat, Kerala and Punjab for simultaneous TB and Covid assessment; an artificial intelligence-based diagnostics solution to scan chest X-rays and detect abnormalities.
Various organisations leveraged digital platforms to conduct training and information sessions for frontline workers. The range of such services and their providers is vast including e-Sanjeevani, Swasth, Practo, Portea, TeCHO, Anmol, to name just a few.
The involvement of community-based organisations in the form of self-help groups (SHGs) and village organisations reinforced their potential for last-mile services. Active TB case finding by community health volunteers through outreach and awareness; demand generation for services and provision of timely information to pregnant women by volunteer groups through helpline numbers; support for essential health service delivery through panchayati raj institutions contributed to strengthening health services.
The Indian postal department was leveraged for its extensive postal network as an alternative logistics chain for delivery of family planning commodities. Social franchising model for TB diagnosis and drug dispensation via e-pharmacies to the doorsteps of patients was also utilised.
India saw many innovations rolled out, although not necessarily at scale and most not evaluated for impact. Based on rigorous impact evaluations, there is potential for scale and convergence. It is not that this potential is not recognised by the government. The introduction of telemedicine guidelines and the launch of the National Digital Health Mission provide a foundation for greater leverage of the digital platform. Admittedly, limited internet penetration in rural India, gender disparity in internet usage, data privacy and data-sharing ethics concerns limit the impact of digital platforms, but an increasing focus on health technology platforms can address, to some extent, the needs of information, triaging, counselling, consultation, scheduling visits, home delivery of drugs, and remote follow-up reducing some of the demand- and supply-side challenges.
Similarly, a stronger policy environment can enable the 70 million SHG women members to play an institutionalised role in health service functions, such as behaviour change interventions, demand for essential services, community-led accountability of health systems and services.
The pandemic saw multiple innovations surface, some deployed in small geographies, some by private organisations and others by the government, most not evaluated for impact. These innovations merit policy attention — in assessing their impact, in their geographic scale, in convergence of currently fragmented services, and in developing meaningful partnerships with private innovators for public adoption.
Scaling innovations requires attention to at least three aspects. One, assessment of innovation impact and certification, which, in turn, will require institutional mechanisms that can enable this. Second, a policy environment that encourages and facilitates public contracting of innovations, in a context where the benefits of purchasing existing, tried-and-tested products/services in the public system are large. Third, grant-and-loan mechanisms that enable innovators to address the needs of the health care system. The platforms on which these innovations are deployed are under-leveraged, with the pandemic demonstrating the opportunity to build on these innovations, leading to a stronger health systems response.
Sandhya Venkateswaran is fellow, Lancet Citizen’s Commission on Reimagining India’s Health System
The views expressed are personal